E-Cigarette Use Among Youth

and Young Adults: A Report of

the Surgeon General

2016 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Office of the Surgeon General 

Rockville, MD 
National Library of Medicine Cataloging-in-Publication Data 

Names: United States. Public Health Service. Office of the Surgeon General, issuing body. | National 

Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and 

Health, issuing body. 

Title: E-cigarette use among youth and young adults : a report of the Surgeon General. 

Description: Atlanta, GA : U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on 

Smoking and Health, 2016. | Includes bibliographical references. 

Subjects: MESH: Electronic Cigarettes – utilization. | Smoking – adverse effects. | Electronic Cigarettes – 

adverse effects. | Tobacco Industry. | Young Adult. | Adolescent. | United States. 

Classification: NLM QV 137 

U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Center for Chronic Disease Prevention and 	Health Promotion 

Office on Smoking and Health 

For more information 

For more information about the Surgeon General’s report, visit www.surgeongeneral.gov. 

To download copies of this document, go to www.cdc.gov/tobacco. 

To order copies of this document, go to www.cdc.gov/tobacco and click on Publications 

Catalog or call 1-800-CDC-INFO (1-800-232-4636); TTY: 1-888-232-6348. 

Suggested Citation 

U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young 

Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and Health, 2016. 

Use of trade names is for identification only and does not constitute endorsement by the 

U.S. Department of Health and Human Services. 
Message from Sylvia Burwell 

Secretary, U.S. Department of Health and Human Services 

The mission of the Department of Health and Human Services is to enhance and protect the 

health and well-being of all Americans. This report confirms that the use of electronic cigarettes (or 

e-cigarettes) is growing rapidly among American youth and young adults. While these products are 

novel, we know they contain harmful ingredients that are dangerous to youth. Important strides have 

been made over the past several decades in reducing conventional cigarette smoking among youth and 

young adults. We must make sure this progress is not compromised by the initiation and use of new 

tobacco products, such as e-cigarettes. That work is already underway. 

To protect young people from initiating or continuing the use of e-cigarettes, actions must be 

taken at the federal, state, and local levels. At the federal level, the U.S. Food and Drug Administration 

(FDA)—under authority granted to it by Congress under the Family Smoking Prevention and Tobacco 

Control Act of 2009—took a historic step to protect America’s youth from the harmful effects of using 

e-cigarettes by extending its regulatory authority over the manufacturing, distribution, and marketing 

of e-cigarettes. Through such action, FDA now requires minimum age restrictions to prevent sales 

to minors and prohibits sales through vending machines (in any facility that admits youth), and will 

require products to carry a nicotine warning. 

We have more to do to help protect Americans from the dangers of tobacco and nicotine, especially our youth. As cigarette smoking among those under 18 has fallen, the use of other nicotine 

products, including e-cigarettes, has taken a drastic leap. All of this is creating a new generation of 

Americans who are at risk of nicotine addiction. 

The findings from this report reinforce the need to support evidence-based programs to prevent 

youth and young adults from using tobacco in any form, including e-cigarettes. The health and wellbeing of our nation’s young people depend on it. 

iii 

Foreword 

Tobacco use among youth and young adults in any form, including e-cigarettes, is not safe. In 

recent years, e-cigarette use by youth and young adults has increased at an alarming rate. E-cigarettes 

are now the most commonly used tobacco product among youth in the United States. This timely report 

highlights the rapidly changing patterns of e-cigarette use among youth and young adults, assesses 

what we know about the health effects of using these products, and describes strategies that tobacco 

companies use to recruit our nation’s youth and young adults to try and continue using e-cigarettes. 

The report also outlines interventions that can be adopted to minimize the harm these products cause 

to our nation’s youth. 

E-cigarettes are tobacco products that deliver nicotine. Nicotine is a highly addictive substance, 

and many of today’s youth who are using e-cigarettes could become tomorrow’s cigarette smokers. 

Nicotine exposure can also harm brain development in ways that may affect the health and mental 

health of our kids. 

E-cigarette use among youth and young adults is associated with the use of other tobacco products, including conventional cigarettes. Because most tobacco use is established during adolescence, 

actions to prevent our nation’s young people from the potential of a lifetime of nicotine addiction are 

critical. 

E-cigarette companies appear to be using many of the advertising tactics the tobacco industry 

used to persuade a new generation of young people to use their products. Companies are promoting 

their products through television and radio advertisements that use celebrities, sexual content, and 

claims of independence to glamorize these addictive products and make them appealing to young 

people. 

Comprehensive tobacco control and prevention strategies for youth and young adults should 

address all tobacco products, including e-cigarettes. Further reductions in tobacco use and initiation 

among youth and young adults are achievable by regulating the manufacturing, distribution, marketing, and sales of all tobacco products—including e-cigarettes, and particularly to children—and 

combining those approaches with other proven strategies. These strategies include funding tobacco 

control programs at levels recommended by the Centers for Disease Control and Prevention (CDC); 

increasing prices of tobacco products; implementing and enforcing comprehensive smokefree laws; and 

sustaining hard-hitting media campaigns, such as CDC’s Tips from Former Smokers that encourages 

smokers to quit for good, and FDA’s Real Cost that is aimed at preventing youth from trying tobacco and 

reducing the number of youth who move from experimenting to regular use. We can implement these 

cost-effective, evidence-based, life-saving strategies now. Together with additional effort and support, 

we can protect the health of our nation’s young people. 

Thomas R. Frieden, M.D., M.P.H. 

Director 

Centers for Disease Control and Prevention 

v 

Preface 

from the Surgeon General 

E-cigarette use among U.S. youth and young adults is now a major public health concern. 

E-cigarette use has increased considerably in recent years, growing an astounding 900% among high 

school students from 2011 to 2015. These products are now the most commonly used form of tobacco 

among youth in the United States, surpassing conventional tobacco products, including cigarettes, 

cigars, chewing tobacco, and hookahs. Most e-cigarettes contain nicotine, which can cause addiction 

and can harm the developing adolescent brain. 

Compared with older adults, the brain of youth and young adults is more vulnerable to the negative consequences of nicotine exposure. The effects include addiction, priming for use of other addictive substances, reduced impulse control, deficits in attention and cognition, and mood disorders. 

Furthermore, fetal exposure to nicotine during pregnancy can result in multiple adverse consequences, 

including sudden infant death syndrome, altered corpus callosum, auditory processing deficits, effects 

on behaviors and obesity, and deficits in attention and cognition. Ingestion of e-cigarette liquids containing nicotine can also cause acute toxicity and possibly death if the contents of refill cartridges or 

bottles containing nicotine are consumed. 

This report highlights what we know and do not know about e-cigarettes. Gaps in scientific evidence do exist, and this report is being issued while these products and their patterns of use continue to 

change quickly. For example, the health effects and potentially harmful doses of heated and aerosolized 

constituents of e-cigarette liquids—including solvents, flavorants, and toxicants—are not completely 

understood. However, although e-cigarettes generally emit fewer toxicants than combustible tobacco 

products, we know that aerosol from e-cigarettes is not harmless. 

Although we continue to learn more about e-cigarettes with each passing day, we currently know 

enough to take action to protect our nation’s young people from being harmed by these products. 

Previous reports of the Surgeon General have established that nearly all habitual tobacco use begins 

during youth and young adulthood. To prevent and reduce the use of e-cigarettes by youth and young 

adults, we must work together as a society. We must implement proven prevention and education strat

egies. Health care providers, parents, teachers, and other caregivers should advise youth about the 

dangers of nicotine and discourage tobacco use in any form, including e-cigarettes. They can set a posi

tive example by being tobacco-free and encouraging those who already use these products to quit. Free 

help is available at 1-800-QUIT-NOW or 

­

­

http://www.smokefree.gov. Preventing tobacco use in any form 

among youth and young adults is critical to ending the tobacco epidemic in the United States. 

Vivek H. Murthy, M.D., M.B.A. 

U.S. Surgeon General 

vii 

ix 

E-Cigarette Use Among Youth and Young Adults

Acknowledgments 

This report was prepared by the U.S. Department of Health 

and Human Services under the general direction of the 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health. 

Vice Admiral (VADM) Vivek H. Murthy, M.D., M.B.A., 

Surgeon General, Office of the Surgeon General, Office 

of the Secretary, U.S. Department of Health and Human 

Services, Washington, D.C. 

Thomas R. Frieden, M.D., M.P.H., Director, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Ursula E. Bauer, Ph.D., M.P.H., Director, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Dana Shelton, M.P.H., Deputy Director, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Peter A. Briss, M.D., M.P.H., Medical Director, National 

Center for Chronic Disease Prevention and Health 

Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Rachel Kaufmann, Ph.D., M.P.H., Associate Director for 

Science, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Corinne Graffunder, Dr.P.H., M.P.H., Director, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Editors of the report were 

Cheryl L. Perry, Ph.D., Senior Scientific Editor, Professor 

and Regional Dean, The Rockwell Distinguished Chair 

in Society and Health, The University of Texas Health 

Science Center at Houston (UTHealth) School of Public 

Health, Austin, Texas. 

Melissa Harrell, Ph.D., M.P.H., Senior Scientific Editor, 

Associate Professor, Department of Health Promotion and 

Behavioral Sciences and the Michael & Susan Dell Center 

for Healthy Living, The University of Texas Health Science 

Center at Houston (UTHealth) School of Public Health, 

Austin, Texas. 

MeLisa R. Creamer, Ph.D., M.P.H., Senior Scientific Editor, 

Faculty Associate, Department of Health Promotion and 

Behavioral Sciences and the Michael & Susan Dell Center 

for Healthy Living, The University of Texas Health Science 

Center at Houston (UTHealth) School of Public Health, 

Austin, Texas. 

Steven Kelder, Ph.D., Senior Scientific Editor, Beth Toby 

Grossman Distinguished Professor of Spirituality and 

Healing; Associate Regional Dean; Co-Director, Michael & 

Susan Dell Center for Healthy Living; Professor, Division 

of Epidemiology, Human Genetics, and Environmental 

Sciences, The University of Texas Health Science Center 

at Houston (UTHealth) School of Public Health, Austin, 

Texas. 

Brian King, Ph.D., Senior Associate Editor, Deputy 

Director for Research Translation, Office on Smoking and 

Health, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Leslie A. Norman, M.B.A., Managing Editor, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Peter L. Taylor, M.B.A., Technical Editor, Fairfax, Virginia. 

Contributing editors were 

Thomas Eissenberg, Ph.D., Director, Center for the 

Study of Tobacco Products; Professor of Psychology 

(Health Program), College of Humanities and Sciences 

and Member Scientist, Massey Cancer Center, Virginia 

Commonwealth University, Richmond, Virginia. 

Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland. 
A Report of the Surgeon General

x

Pamela Ling, M.D., M.P.H., Professor, Division of General 

Internal Medicine, Department of Medicine, Center for 

Tobacco Control Research and Education, University of 

California, San Francisco, California.

Mark Parascandola, Ph.D., M.P.H., Epidemiologist, 

Tobacco Control Research Branch, Behavioral Research 

Program, Division of Cancer Control and Population 

Sciences, National Cancer Institute, National Institutes of 

Health, Rockville, Maryland.

Jennifer L. Pearson, Ph.D., M.P.H., Research Investigator, 

The Schroeder Institute for Tobacco Research and Policy 

Studies at Truth Initiative, Washington, D.C.; Adjunct 

Assistant Professor, Department of Health, Behavior, 

and Society, Bloomberg School of Public Health, Johns 

Hopkins University, Baltimore, Maryland.

Jonathan M. Samet, M.D., M.S., Distinguished Professor 

and Flora L. Thornton Chair, Department of Preventive 

Medicine, Keck School of Medicine; Director, Institute 

for Global Health, University of Southern California, Los 

Angeles, California.

Andrea C. Villanti, Ph.D., M.P.H., Director for 

Regulatory Science and Policy, The Schroeder Institute 

for Tobacco Research and Policy Studies at Truth 

Initiative, Washington, D.C.; Adjunct Assistant Professor, 

Department of Health, Behavior, and Society, Bloomberg 

School of Public Health, Johns Hopkins University, 

Baltimore, Maryland.

Contributing authors were

Melissa D. Blank, Ph.D., Assistant Professor, Department 

of Psychology, West Virginia University, Morgantown, 

West Virginia.

Frank J. Chaloupka, Ph.D., Director, Health Policy Center, 

Institute for Health Research and Policy, and Distinguished 

Professor, Department of Economics, University of Illinois 

at Chicago, Chicago, Illinois.

Shari P. Feirman, Ph.D., M.S., Project Director for 

Regulatory Science and Policy, The Schroeder Institute for 

Tobacco Research and Policy Studies at Truth Initiative, 

Washington, D.C.

Jonathan Foulds, Ph.D., Professor, Departments of Public 

Health Sciences and Psychiatry, College of Medicine, Penn 

State University, Hershey, Pennsylvania.

Allison M. Glasser, M.P.H., Senior Project Manager, The 

Schroeder Institute for Tobacco Research and Policy 

Studies at Truth Initiative, Washington, D.C. 

Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor 

of Oncology, Department of Health Behavior, Roswell Park 

Cancer Institute, Buffalo, New York.

Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland.

Lisa Henriksen, Ph.D., Senior Research Scientist, 

Stanford Prevention Research Center, Department of 

Medicine, School of Medicine, Stanford University, Palo 

Alto, California.

Jidong Huang, Ph.D., Senior Research Scientist, Institute 

for Health Research and Policy, University of Illinois at 

Chicago, Chicago, Illinois.

Lauren K. Katz, M.P.H., Research Associate I, The 

Schroeder Institute for Tobacco Research and Policy 

Studies at Truth Initiative, Washington, D.C.

Frances Leslie, Ph.D., Vice Provost for Graduate Education; 

Dean of the Graduate Division; Professor of Pharmacology 

and Anatomy and Neurobiology, University of California, 

Irvine, California.

M. Jane Lewis, Dr.Ph., Associate Professor, Health 

Education and Behavioral Science and Center for Tobacco 

Studies, School of Public Health, Rutgers University, New 

Brunswick, New Jersey. 

Kristy Marynak, M.P.P., Public Health Analyst, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia.

Mark Parascandola, Ph.D., M.P.H., Epidemiologist, 

Tobacco Control Research Branch, Behavioral Research 

Program, Division of Cancer Control and Population 

Sciences, National Cancer Institute, National Institutes of 

Health, Rockville, Maryland.

Terry F. Pechacek, Ph.D., Professor and Interim Division 

Director of Health Management and Policy, School of 

Public Health, Georgia State University, Atlanta, Georgia. 
xi 

E-Cigarette Use Among Youth and Young Adults

Gabbi Promoff, M.A., Associate Director for Policy, Office 

on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Kurt M. Ribisl, Ph.D., Professor, Department of Health 

Behavior, University of North Carolina Gillings School 

of Global Public Health; Program Leader in Cancer 

Prevention and Control, University of North Carolina 

Lineberger Comprehensive Cancer Center, Chapel Hill, 

North Carolina. 

April Roeseler, B.S.N., M.S.P.H., Chief, California Tobacco 

Control Program, California Department of Public Health, 

Sacramento, California. 

Jonathan M. Samet, M.D., M.S., Distinguished Professor 

and Flora L. Thornton Chair, Department of Preventive 

Medicine, Keck School of Medicine; Director, Institute 

for Global Health, University of Southern California, Los 

Angeles, California. 

Laura R. Stroud, Ph.D., Senior Research Scientist, 

Centers for Behavioral and Preventive Medicine, The 

Miriam Hospital; Associate Professor, Department of 

Psychiatry and Human Behavior, Alpert Medical School, 

and Department of Behavioral and Social Sciences, School 

of Public Health, Brown University, Providence, Rhode 

Island. 

Prue Talbot, Ph.D., Director, University of California, 

Riverside Stem Cell Center and Core; Professor of Cell 

Biology, Department of Cell Biology and Neuroscience, 

University of California, Riverside, California. 

Mark Travers, Ph.D., M.S., Assistant Professor of Oncology, 

Department of Health Behavior and Air Pollution Exposure 

Research Laboratory, Roswell Park Cancer Institute, 

Buffalo, New York. 

Scott Weaver, Ph.D., M.A., Assistant Professor, Division of 

Epidemiology and Biostatistics, School of Public Health, 

Georgia State University, Atlanta, Georgia. 

Reviewers were 

David B. Abrams Ph.D., Executive Director, The Schroeder 

Institute for Tobacco Research and Policy Studies at Truth 

Initiative, Washington, D.C.; Professor, Department of 

Health, Behavior, and Society, Bloomberg School of 

Public Health, Johns Hopkins University, Baltimore, 

Maryland; Professor of Oncology, Georgetown University 

Medical Center, Lombardi Comprehensive Cancer Center 

(adjunct), Washington, D.C. 

Heather Rubino Althouse, Senior Regulatory Counsel, 

Office of Compliance and Enforcement, Center for 

Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

René A. Arrazola, M.P.H., Epidemiologist, Epidemiology 

Branch, Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

David L. Ashley, Ph.D., Director, Office of Science, Center 

for Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

Cathy L. Backinger, Ph.D., M.P.H., Deputy Director for 

Research, Office of Science, Center for Tobacco Products, 

U.S. Food and Drug Administration, Silver Spring, 

Maryland. 

Tracey E. Barnett, Ph.D., Associate Professor, Department 

of Epidemiology, College of Public Health and Health 

Professions and College of Medicine, University of Florida, 

Gainesville, Florida. 

Neal L. Benowitz, M.D., Professor of Medicine, 

Bioengineering, and Therapeutic Sciences, Chief, Division 

of Clinical Pharmacology, University of California, San 

Francisco, California. 

Jay M. Bernhardt, Ph.D., M.P.H., Interim Dean and 

Professor, Moody College of Communication; Founding 

Director, Center for Health Communication, The 

University of Texas, Austin, Texas. 

Nazleen Bharmal, M.D., Ph.D., M.P.P., Director of Science 

and Policy, Office of the Surgeon General, U.S. Department 

of Health and Human Services, Washington, D.C. 

Allan M. Brandt, Ph.D., Amalie Moses Kass Professor of 

the History of Medicine, Department of Global Health 

and Social Medicine, Harvard University Medical School, 

Boston, Massachusetts. 

April Brubach, M.A., Director, Division of Public Health 

Education, Office of Health Communication and 

Education, Center for Tobacco Products, U.S. Food and 

Drug Administration, Silver Spring, Maryland. 

Priscilla Callahan-Lyon, M.D., Medical Branch Chief, 

Division of Individual Health Science, Office of Science, 

Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 
A Report of the Surgeon General

xii

Frank J. Chaloupka, Ph.D., Director, Health Policy Center, 

Institute for Health Research and Policy; Distinguished 

Professor, Department of Economics, University of Illinois 

at Chicago, Chicago, Illinois.

Ii-Lun Chen, M.D., Director, Division of Individual Health 

Science, Office of Science, Center for Tobacco Products, U.S. 

Food and Drug Administration, Silver Spring, Maryland.

Beverly Chernaik, J.D., Director, Office of Regulations, 

Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 

Joanna E. Cohen, Ph.D., Director, Institute for Global 

Tobacco Control; Bloomberg Professor of Disease 

Prevention, Department of Health, Behavior, and Society, 

Bloomberg School of Public Health, Johns Hopkins 

University, Baltimore, Maryland.

Catherine G. Corey, M.S.P.H., Epidemiologist, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland.

Kathleen Crosby, Director, Office of Health Communication 

and Education, Center for Tobacco Products, U.S. Food 

and Drug Administration, Silver Spring, Maryland.

Cristine D. Delnevo, Ph.D., M.P.H., Professor and Director, 

Center for Tobacco Studies, Rutgers School of Public 

Health, New Brunswick, New Jersey.

Lauren M. Dutra, Sc.D., M.A., Postdoctoral Fellow, Center 

for Tobacco Control Research and Education, University of 

California, San Francisco, California.

Lucinda J. England, M.D., M.S.P.H., Medical Officer, Office 

on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Atlanta, Georgia. 

Michael P. Eriksen, Sc.D., Sc.M., Dean and Regents’ Professor, 

Division of Health Management and Policy, School of Public 

Health, Georgia State University, Atlanta, Georgia.

Michael C. Fiore, M.D., M.P.H., M.B.A., University of Wisconsin 

Hilldale Professor of Medicine; Director, Center for Tobacco 

Research and Intervention, University of Wisconsin School of 

Medicine and Public Health, Madison, Wisconsin.

Neal D. Freedman, Ph.D., M.P.H., Senior Investigator, 

Metabolic Epidemiology Branch, Division of Cancer 

Epidemiology and Genetics, National Cancer Institute, 

National Institutes of Health, Rockville, Maryland.

Elizabeth M. Ginexi, Ph.D., Program Director, Tobacco 

Control Research Branch, Division of Cancer Control and 

Population Sciences, National Cancer Institute, National 

Institutes of Health, Rockville, Maryland.

Gary A. Giovino, Ph.D., M.S., Professor and Chair, 

Department of Community Health and Health Behavior, 

School of Public Health and Health Professions, University 

at Buffalo, The State University of New York, Buffalo, New 

York.

Stanton A. Glantz, Ph.D., Professor of Medicine and 

American Legacy Foundation Distinguished Professor in 

Tobacco Control; Director, Center for Tobacco Control 

Research and Education, University of California, San 

Francisco, California.

Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor 

of Oncology, Department of Health Behavior, Roswell Park 

Cancer Institute, Buffalo, New York.

Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland.

Bonnie Halpern-Felsher, Ph.D., FSAHM, Director of 

Research, Professor, Division of Adolescent Medicine, 

Stanford University, Palo Alto, California.

Dorothy K. Hatsukami, Ph.D., Forster Family Professor in 

Cancer Prevention, Masonic Cancer Center, University of 

Minnesota, Minneapolis, Minnesota.

Corinne Husten, M.D., M.P.H., Senior Medical Advisor, 

Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland.

Frances Jensen, M.D., F.A.C.P., Professor and Chair, 

Neurology Department, Perelman School of Medicine, 

University of Pennsylvania, Philadelphia, Pennsylvania.

Ronald L. Johnson, Ph.D., Program Director, DNA and 

Chromosome Aberrations Branch, Division of Cancer 

Biology, National Cancer Institute, National Institutes of 

Health, Bethesda, Maryland.

Sarah E. Johnson, Ph.D., Social Scientist, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland.
xiii 

E-Cigarette Use Among Youth and Young Adults

Annette R. Kaufman, Ph.D., M.P.H., Health Scientist and 

Program Director, Tobacco Control Research Branch, 

Behavioral Research Program, Division of Cancer Control 

and Population Sciences, National Cancer Institute, 

National Institutes of Health, Rockville, Maryland. 

Ryan David Kennedy, Ph.D., Assistant Professor, Institute 

for Global Tobacco Control, Department of Health, 

Behavior, and Society, Bloomberg School of Public Health, 

Johns Hopkins University, Baltimore, Maryland. 

Jonathan D. Klein, M.D., M.P.H., F.A.A.P., Associate 

Executive Director; Director, Julius B. Richmond Center, 

American Academy of Pediatrics, Elk Grove Village, 

Illinois. 

Suchitra Krishnan-Sarin, Ph.D., Professor, Department 

of Psychiatry, School of Medicine, Yale University, New 

Haven, Connecticut. 

Lauren K. Lempert, J.D., M.P.H., Associate Specialist, 

Center for Tobacco Control Research and Education, 

University of California, San Francisco, California. 

Maggie Mahoney, J.D., Executive Director, Tobacco 

Control Legal Consortium at the Public Health Law 

Center, St. Paul, Minnesota. 

Tim McAfee, M.D., Medical Officer, Office on Smoking and 

Health, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Daniel McGoldrick, M.A., Vice President, Global Health 

Advocacy Incubator, Campaign for Tobacco-Free Kids, 

Washington, D.C. 

Cindy Miner, Ph.D., Associate Director for Scientific 

Communication, Office of Science, Center for Tobacco 

Products, U.S. Food and Drug Administration, Silver 

Spring, Maryland. 

Matthew L. Myers, J.D., President, Campaign for TobaccoFree Kids, Washington, D.C. 

Linda J. Neff, Ph.D., Senior Epidemiologist, Epidemiology 

Branch, Office on Smoking and Health, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Richard J. O’Connor, Ph.D., Member and Professor of 

Oncology, Department of Health Behavior, Division of 

Cancer Prevention and Population Sciences, Roswell Park 

Cancer Institute, Buffalo, New York. 

Mark Parascandola, Ph.D., M.P.H., Epidemiologist, 

Tobacco Control Research Branch, Behavioral Research 

Program, Division of Cancer Control and Population 

Sciences, National Cancer Institute, National Institutes of 

Health, Rockville, Maryland. 

Terry F. Pechacek, Ph.D., Professor and Interim Division 

Director of Health Management and Policy, School of 

Public Health, Georgia State University, Atlanta, Georgia. 

Alexander Persoskie, Ph.D., Social Scientist, Center for 

Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

John P. Pierce, Ph.D., Professor Emeritus, Department of 

Family Medicine and Public Health and the Moores Cancer 

Center, University of California, San Diego, La  Jolla, 

California. 

David W. Racine, M.S., Senior Program Management 

Officer, Office of Compliance and Enforcement, Center for 

Tobacco Products, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

Chad J. Reissig, Ph.D., Addiction Branch Chief, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 

Joelle Robinson, M.P.H., Social Scientist, Office of 

Science, Center for Tobacco Products, U.S. Food and Drug 

Administration, Silver Spring, Maryland. 

Jonathan M. Samet, M.D., M.S., Distinguished Professor 

and Flora L. Thornton Chair, Department of Preventive 

Medicine, Keck School of Medicine; Director, Institute 

for Global Health, University of Southern California, Los 

Angeles, California. 

Peter G. Shields, M.D., Deputy Director, Comprehensive 

Cancer Center, James Cancer Hospital; Professor, College 

of Medicine, The Ohio State University, Columbus, Ohio. 

Ann Simoneau, J.D., M.B.A., Director, Office of Compliance 

and Enforcement, Center for Tobacco Products, U.S. Food 

and Drug Administration, Silver Spring, Maryland. 
A Report of the Surgeon General

Theodore A. Slotkin, Ph.D., Professor, Department of 

Pharmacology and Cancer Biology, Duke University 

Medical Center, Durham, North Carolina. 

Anne Sowell, Ph.D., Health Scientist, National Center 

for Chronic Disease Prevention and Health Promotion, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia. 

Erin L. Sutfin, Ph.D., Associate Professor and Vice Chair, 

Department of Social Sciences and Health Policy, Division 

of Public Health Sciences, Wake Forest School of Medicine, 

Wake Forest University, Winston-Salem, North Carolina. 

Robert E. Vollinger, Jr., M.S.P.H., (Dr.P.H. Candidate), 

Program Director and Public Health Advisor, Tobacco 

Control Research Branch, Behavioral Research Program, 

Division of Cancer Control and Population Sciences, 

National Cancer Institute, National Institutes of Health, 

Rockville, Maryland. 

Kenneth E. Warner, Ph.D., Avedis Donabedian 

Distinguished University Professor of Public Health, 

Department of Health Management and Policy, University 

of Michigan School of Public Health, Ann Arbor, 

Michigan. 

Geoffrey Ferris Wayne, M.A., Research Consultant, 

Sebastopol, California. 

Deborah M. Winn, Ph.D., Deputy Director, Division 

of Cancer Control and Population Sciences, National 

Cancer Institute, National Institutes of Health, Rockville, 

Maryland. 

Mitchell Zeller, J.D., Director, Center for Tobacco 

Products, U.S. Food and Drug Administration, Silver 

Spring, Maryland. 

Other contributors were 

Katherine J. Asman, M.S.P.H., Statistician, Biostatistics 

and Epidemiology Division, RTI International, Atlanta, 

Georgia. 

Adam J. Burke, M.A., Research Associate Lead, The 

Monitoring the Future Study, University of Michigan, Ann 

Arbor, Michigan. 

Dayana Chanson, M.P.H., Research Associate to Jonathan 

M. Samet, M.D., M.S., Department of Preventive Medicine, 

Keck School of Medicine, University of Southern 

California, Los Angeles, California. 

Tara Christine Chu, M.P.H., Research Associate to 

Jonathan M. Samet, M.D., M.S., Department of Preventive 

Medicine, Keck School of Medicine, University of Southern 

California, Los Angeles, California. 

Stephanie L. Clendennen, M.P.H., Predoctoral Fellow, 

Tobacco Center of Regulatory Science on Youth and 

Young Adults, The University of Texas Health Science 

Center at Houston (UTHealth) School of Public Health, 

Austin, Texas. 

Sarah J. Cross, Graduate Student Researcher, Department 

of Anatomy and Neurobiology, University of California, 

Irvine, California. 

Nicholas J. Felicione, Graduate Research Assistant, 

Department of Psychology, West Virginia University, 

Morgantown, West Virginia. 

Kyle R. Gregory, J.D., M.S.H.A., Postdoctoral Research 

Associate, Tobacco Center of Regulatory Science, School of 

Public Health, Georgia State University, Atlanta, Georgia. 

Emily T. Hébert, M.P.H., Doctoral Student, Michael & 

Susan Dell Center for Healthy Living, The University 

of Texas Health Science Center at Houston (UTHealth) 

School of Public Health, Austin, Texas. 

Erin O’Connor Landau, M.S., Data Analyst, DB Consulting 

Group (Contractor), Office on Smoking and Health, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Pamela Lemos, M.S., Public Health Analyst, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Gerald V. [Simon] McNabb, Lead Public Health Analyst, 

Office on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention, Washington, D.C. 

Ronald L. Johnson, Ph.D., Program Director, DNA and 

Chromosome Aberrations Branch, Division of Cancer 

Biology, National Cancer Institute, National Institutes of 

Health, Bethesda, Maryland. 

Hoda S. Magid, M.H.S., Center for Tobacco Control 

Research and Education, University of California, 

San Francisco, California. 

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xv 

E-Cigarette Use Among Youth and Young Adults

Dale Mantey, M.P.A., Predoctoral Fellow, Tobacco Center 

of Regulatory Science on Youth and Young Adults, The 

University of Texas Health Science Center at Houston 

(UTHealth) School of Public Health, Austin, Texas. 

Mandie Mills, Photographer, Office of the Associate 

Director for Communication, Centers for Disease Control 

and Prevention, Atlanta, Georgia. 

Richard Miech, Ph.D., Professor, Institute for Social 

Research, University of Michigan, Ann Arbor, Michigan. 

Luz M. Moncayo, Executive Assistant to Jonathan M. 

Samet, M.D., M.S., Department of Preventive Medicine, 

Keck School of Medicine, Institute for Global Health, 

University of Southern California, Los Angeles, California. 

Maureen O’Brien, J.D., Staff Attorney, Tobacco Control 

Legal Consortium at the Public Health Law Center, 

St. Paul, Minnesota. 

Patrick M. O’Malley, Ph.D., Research Professor, Survey 

Research Center, Institute for Social Research, University 

of Michigan, Ann Arbor, Michigan. 

Gabriela V. Portillo, Masters Student, Michael & Susan 

Dell Center for Healthy Living, The University of Texas 

Health Science Center at Houston (UTHealth) School of 

Public Health, Austin, Texas. 

Anna Teplinskaya, M.D., M.P.H., Public Health Analyst, 

Epidemiology Branch, Office on Smoking and Health, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Tenecia Smith, M.P.H., Data Analyst, DB Consulting Group 

(Contractor), Office on Smoking and Health, National 

Center for Chronic Disease Prevention and Health 

Promotion, Centers for Disease Control and Prevention, 

Atlanta, Georgia. 

Kathryn E. Szynal, Editorial Assistant, McNeal 

Professional Services (Contractor), Office on Smoking and 

Health, National Center for Chronic Disease Prevention 

and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Teresa Wang, Ph.D., M.S., Epidemic Intelligence Service 

Officer, Lieutenant, U.S. Public Health Service, Office on 

Smoking and Health, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia. 

Jennifer Whitmill, M.P.H., Data Analyst, DB Consulting 

Group (Contractor), Office on Smoking and Health, 

National Center for Chronic Disease Prevention and 

Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia 

 

 

 

 

 

E-Cigarette Use Among Youth and Young Adults 

Chapter 1 Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 1

Introduction 3
 

Major Conclusions 5
 

Chapter Conclusions 6
 

Historical Background 8
 

The E-Cigarette 10
 

E-Cigarette Companies 14
 

Federal Regulation of E-Cigarettes 15
 

Summary 18
 

References 19
 

Chapter 2 Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 25
 

Introduction 27
 

Key Findings 28
 

Evidence Summary 86
 

Conclusions 88
 

References 89
 

Chapter 3 Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 95
 

Introduction 97
 

Conclusions from Previous Surgeon General’s Reports 97
 

Health Effects of E-Cigarette Use 100
 

Evidence Summary 124
 

Conclusions 125
 

References 126
 

Chapter 4 Activities of the E-Cigarette Companies 147
 

Introduction 149
 

Manufacturing and Price 149
 

Marketing and Promotion of E-Cigarettes 157
 

Evidence Summary 172
 

Conclusions 172
 

References 173
 

Chapter 5 E-Cigarette Policy and Practice Implications 181
 

Introduction 183
 

Critical Issues Related to Policies on E-Cigarettes in 2016 184
 

Potential Public Policy Approaches 187
 

Case Studies 224
 

Summary and Recommendations 225
 

Conclusions 226
 

References 227
 

xvii 
 

The Call to Action 235
 

The Call to Action on E-Cigarette Use Among Youth and Young Adults 237
 

Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Youth 


Goal 5. Curb Advertising and Marketing that Encourages Youth and Young Adults 


Goal 1. First, Do No Harm 237
 

and Young Adults 239
 

Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protect Public Health 241
 

Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and Young Adults 243
 

to Use E-Cigarettes 246
 

Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigarettes 247
 

Conclusions 249
 

References 250
 

List of Abbreviations 253
 

List of Tables and Figures 257
 

Index 261
 

xviii